ADD/ADHD Individualized Healthcare Plan (IHCP) Student Name: ______

ADD/ADHD Individualized Healthcare Plan (IHCP)

Student: ______Date of Birth: ______Grade: ______Teacher/Staff Contact Person: ______

Student’s Secondary Health Concerns (if applicable): ______

Nursing Diagnoses: Knowledge deficit related to ADHD/ADD disease management and prescribed treatment regimen (NANDA 00126) Impaired social interaction related to impulsive behavior (NANDA 00052) Student Goal(s): Student will demonstrate understanding of the disease process and management. Student will display appropriate behavior.

NIC INTERVENTIONS NOC OUTCOME INDICATORS

) l a i t i Behavior Management (4352) Social Interaction Skills (1502) n I a. Cooperates with others (150203)

&  Develop a behavioral management plan that is carried out consistently by

e t school staff b. Exhibits consideration (150207) a D

(  Determine appropriate behavioral expectations and consequences given c. Uses assertive behaviors as appropriate (150205)

d the patient’s level of cognitive functioning and capacity for self-control d. Appears relaxed (150211) e t e. Uses conflict resolution strategies (150216) n  Instruct in problem–solving skills e  Encourage the expression of feelings in an appropriate manner Never Consistently

m Rarely Sometimes Often Demonstrated Demonstrated e

l  Provide consistent consequences for both desired and undesired

p 1 2 3 4 5 N/A behavior(s) Indicator

m (Date) (Date) (Date) (Date) (Date) (Date) I

_  Praise desired behavior and effort at self-control a. _

_  Refrain from arguing or bargaining about established limits b. _

_  Limit choices, as necessary c. _

_  Administer medication to promote desired behavior changes d. _

_  Assist student and school staff to adapt the school environment to e. _

_ accommodate limitations imposed by chronic inattention and overactivity _ Hyperactivity Level (0915) a. Inability to stay “on task” (091504) b. Impulsivity (091511) c. Difficulty keeping hands to self (091523) Severe No Substantial Moderate Mild Deviation Deviation 1 2 3 4 5 N/A Indicator (Date) (Date) (Date) (Date) (Date) (Date) a. b. c.

School Nurse’s Name: ______Nurse’s Signature: ______Date of IHCP: ______

Revised November 2013 ) l a i t i n I

e t a D (

d e t n e m e l

p ADD/ADHD Individualized Healthcare Plan (IHCP) Student Name: ______m I _

_ Health Education (5510) Knowledge: Disease Process (1803) _ a. Specific disease process (180302) _  Determine current health knowledge and lifestyle behavior of student and _ b. Signs and symptoms (180306) _ family _ c. Potential complications of disease (180309) _  Emphasize importance of healthy patterns of eating, sleeping, exercising, _ d. Precautions to prevent complications (180311)

_ etc. _ No Extensive _ Limited Moderate Substantial Knowledge Knowledge Teaching: Disease Process (5602) 1 2 3 4 5 N/A Indicator  Review & acknowledge student’s knowledge about condition (Date) (Date) (Date) (Date) (Date) (Date)  Describe the disease process, and common signs and symptoms of the a. disease, as appropriate b.  Discuss lifestyle changes that may be required to prevent future c. complications, and/or control the disease process d. _ _

_ Delegation (7650) Caregiver Performance: Direct Care (2205) _

_  Determine the student’s care that needs to be completed a. Knowledge of treatment regimen (220504) _

_  Identify the potential for harm b. Performance of procedure (220516) _

_  Evaluate the competency and training of unlicensed assistive personnel c. Surveillance of health status of student (220508) _

_ (UAP) d. Confidence performing needed task (220513) _

Not Totally

)  Determine the level of supervision needed for the specific delegated

l Slightly Moderately Substantially

a Adequate Adequate i

t intervention or activity i

n 1 2 3 4 5 N/A I

Indicator  Follow-up with UAP on regular basis to evaluate their progress for (Date) (Date) (Date) (Date) (Date) (Date) &

e t completing the specific task a. a

D  Evaluate the outcome of the delegated intervention or activity ( b.

d  Develop emergency care plan, as appropriate c. e t

n d. e m e l p m I

Revised November 2013 ADD/ADHD Individualized Healthcare Plan (IHCP) Student Name: ______) l a i t i n

I Medication Management (2380) Knowledge: Medication (1808)

&  Determine student’s ability to self-medicate, as appropriate a. Identification of the correct name of medication (180802) e t

a  Monitor effectiveness of the medication administration modality b. Medication side effect (180805) D (  Monitor student for therapeutic effect of the medication c. Correct use of prescribed medication (180810) d

e d. Proper medication storage (180812) t  Determine the student’s and UAP’s knowledge about medication

n e. Proper disposal of medication (180815)

e  Teach UAP the method of drug administration, as appropriate

m No Extensive  Instruct student when to seek medical attention Limited Moderate Substantial e

l Knowledge Knowledge p  Review with the student and UAP strategies for managing medication 1 2 3 4 5 N/A

m Indicator

I regimen (Date) (Date) (Date) (Date) (Date) (Date) _

_ a. _

_ b. _

_ c. _

_ d. _

_ e. _ _ _ _

_ Medication Administration (2300) Medication Response (2301) _

_  Verify medication order before administration a. Expected therapeutic effects (230101) _ _

 Monitor student for therapeutic effect of the medication Severely Not )

l Substantially Moderately Mildly

a Compromised Compromised i

t  Monitor student for adverse effects, toxicity, and interactions of the i

n 1 2 3 4 5 N/A I administered medication Indicator &

(Date) (Date) (Date) (Date) (Date) (Date) e t

a a. D (

d e t n e m e l p m I

Revised November 2013 ADD/ADHD Individualized Healthcare Plan (IHCP) Student Name: ______) l a i t i n

I Student Health Status (2005)

& a. Physical health (200501) e t

a b. Mental health (200502) D ( c. School attendance (200503) d

e d. Readiness to learn (200504) t

n e. Return to class after visit to health office (200508) e

m f. Reports to the health office for medications at appropriate time e l (200511) p

m g. Participation in self-care activities (200514) I

_ h. Students with chronic illness or special needs managed according to _

_ IHCP/IEP (200515) _

_ i. Participation in physical activities (200519) _

_ j. Healthy dietary habits (200523) _

_ Severely Not Substantially Moderately Mildly _ Compromised Compromised _ 1 2 3 4 5 N/A Indicator (Date) (Date) (Date) (Date) (Date) (Date) a. b. c. d. e. f. g. h. i. j.

Revised November 2013